Urodynamics Pre-Test
Questionnaire

Please complete this secure pre-test assessment online before your upcoming appointment. Sharing your specific bladder symptoms helps us provide the highest standard of personalized care. It allows Mr. Jesuraj and our clinical team to thoroughly prepare for your visit and tailor the diagnostic equipment to your exact needs. This ensures your final results are interpreted with the highest possible accuracy. It takes approximately 5–8 minutes to complete.

Urodynamics Pre-Test Questionnaire

Gender Selection

Male patient / Female patient selection

I am completing this form as a

Male

Female

Personal Details

Name, DOB, contact details

First Name

Last Name

Date of Birth

Address Line 1

Phone/Mobile

Occupation

Address Line 2

GP Name & Practice (optional)

Urinary History

Symptoms and duration

What is your main urinary symptom?

How long have you had these symptoms?

Less than 3 months

3–12 months

1–5 years

More than 5 years

Tick all symptoms that apply

Needing to urinate frequently

Sudden strong urge to urinate

Waking at night to urinate

Leaking urine

Weak or slow urine stream

Straining to void

Feeling of incomplete emptying

Pain or discomfort passing urine

Previous treatment for bladder or urinary problems?

Medications & Blood Thinners

Medications, blood thinners, allergies

Are you taking any regular medications?

Yes

Please list your medications and doses

Are you taking any blood thinners?

Not Sure

Yes

Which blood thinner(s)?

Do you have any known drug allergies?

Yes

Please describe your allergy and the reaction

Infection & Safety Questions

Infection and safety checks

Do you currently have any symptoms of urine infection? eg: Burning, stinging, cloudy or smelly urine

Yes

⚠ Please contact the clinic before attending if you think you have a current urine infection. Urodynamics cannot be safely performed with an active infection. Call 01642 699 066.

Have you had a urine infection in the past 4 weeks?

Yes

Do you have a urinary catheter in place?

Yes

Are you currently pregnant or could you be pregnant?

Not sure

Yes

Do you have a latex allergy?

Yes

Any other medical conditions or concerns?

IPSS Questionnaire

Prostate symptom score — male patients only

How often have you had the sensation of not emptying your bladder completely after urinating?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How often have you had to urinate again less than 2 hours after you last urinated?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How often have you found that you stopped and started again several times when you urinated?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How often have you found it difficult to postpone urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How often have you had a weak urinary stream?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How often have you had to push or strain to begin urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

How many times do you typically get up to urinate between going to sleep and waking up?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

IPSS Total Score

Quality of life score - If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

0=Delighted

1=Please

2=Mostly satisfied

3=Mixed

4=Mostly dissatisfied

5=Unhappy

6=Terrible

Mild symptoms (score 0–7): Your symptoms are in the mild range. Urodynamics will help confirm the cause.

Moderate symptoms (score 8–19): Your symptoms are in the moderate range.

Severe symptoms (score 20–35): Your symptoms are in the severe range.

OAB Questionnaire

Overactive bladder questionnaire — female patients only

How many times do you urinate during the day (from waking until sleeping)?

1–7 times

8–10 times

11–13 times

14 or more times

How much does this bother you?

How many times do you typically wake at night to urinate?

Never

Once

Twice

3 or more times

How much does this bother you?

How often do you experience a sudden, strong urge to urinate that is difficult to defer?

Never

Less than once a wee

Once a week or more

Once a day

Several times a day

How much does this bother you?

How often do you leak urine before you are able to reach the toilet?

Never

Less than once a wee

Once a week or more

Once a day

Several times a day

How much does this bother you?

ICIQ Questionnaire

Incontinence questionnaire — female patients only

How often do you leak urine?

Never

About once a week or less often

Two or three times a week

About once a day

Several times a day

All the time

How much urine do you usually leak?

None

A small amount

A moderate amount

A large amount

How much does leaking interfere with your everyday life? - 0 = not at all, 10 = a great deal

ICIQ-UI Score

Slight incontinence (score 1–5)

Moderate incontinence (score 6–12)

Severe incontinence (score 13–18)

Very severe incontinence (score 19–21)

When does urine leak? (tick all that apply)

Urine does not leak

Before reaching the toilet

When you cough or sneeze

When you are asleep

When physically active or exercising

After finishing urinating and getting dressed

For no obvious reason

All the time

Concerns & Final Notes

Concerns, diary status, consent

Do you have any worries or questions about the urodynamics procedure?

Is there anything else Mr. Jesuraj should be aware of before your test?

Have you completed your 3-day bladder diary?

Yes — I will bring it to my appointment

Not yet — I will download and complete it now

I have not been given a diary — please provide a link

If you have already completed paper forms, you may upload them here

Choose File

I confirm the information I have provided is accurate to the best of my knowledge. I consent to this information being held by Best Life Clinic / Tees Urology for the purpose of my medical care

Urodynamics Pre-TestQuestionnaire

Gender Selection

Personal Details

Urinary History

Medications & Blood Thinners

Infection & Safety Questions

IPSS Questionnaire

OAB Questionnaire

ICIQ Questionnaire

Concerns & Final Notes

Urodynamics Pre-Test
Questionnaire